C-Sections and the Real Crime

By Rebecca Johnson

Published: April 12, 2004

Prosecutors in Salt Lake City announced last week that they had dropped charges of homicide against a woman who delayed a Cesarean section despite doctors' advice that it was necessary to save the lives of her twins. It was a step in the right direction, but the decision to criminalize the woman's choice -- one of her twins was later delivered stillborn, the other survived with complications, and the mother has pleaded guilty to child endangerment -- was wrong from the start. Not because it violated a patient's general right to privacy or a woman's specific right to make her own choices about reproduction (though it did). The charge was disturbing because it implied that the medical establishment can predict with certainty the best course of action for a fetus in distress. It cannot.

In March 2002, when I was about 25 weeks pregnant, I had a severe case of pregnancy-related hypertension called pre-eclampsia. Like the woman in Utah, I went to the emergency room, where a sonogram revealed that my baby was in distress. My doctor recommended an immediate C-section, saying it was ''his best chance.'' The sonogram also showed that the baby would weigh about two and a half pounds. Unlike the woman in Utah, I took my doctor's advice.

Twenty-four hours later, when my son was removed from my uterus, he weighed a little more than a pound. His eyes were still shut, his skin was translucent and his limbs were thrashing in protest. From the moment I saw him, I knew I'd made a mistake. There was no way such a tiny, unformed creature could survive in this world. Four days later, Luke died in the neonatal intensive care unit.

Like any parent, I grieved over his death. But as I replayed the day over in my mind, what troubled me most was how blindly I had made my decision to have the C-section. Each day a premature baby remains in utero translates into four fewer days in the intensive care unit. Had I known this, I would have insisted that Luke stay in my womb longer. But because I had assumed my pregnancy would be normal, I was not well versed in the facts, or the unpredictable nature, of obstetrics -- a field in which one of the two patients is separated from the doctor by a wall of flesh and blood.

Ultrasound readings can tell us an amazing amount about human gestation. But they are not perfect. Developed around the turn of the century and initially used to detect submarines in World War I, sonar technology was viewed skeptically by obstetricians until 1958, when a Scottish doctor used it to identify a large, easily removable cyst in the stomach of a woman who was thought to have terminal cancer. For tasks like identifying cysts, multiple gestations or an ectopic pregnancy, ultrasound has been a boon to the field. And what mother has not thrilled to the sight of her unborn child sloshing around in a bath of amniotic fluid?

But for more difficult jobs, like identifying defects or predicting fetal weight, the record for ultrasound technology is mixed. In the largest study to date, research sponsored by the National Institutes of Health in 1993 found that in 15,000 low-risk pregnancies, ultrasound detected only 17 percent of fetal structural anomalies before 24 weeks. Human error accounts for much of the problem. Sonograms rely on precise measurements of the fetus. In an emergency-room setting, it's unlikely the person performing the ultrasound will have the expertise necessary to make highly accurate readings. When using highly trained, experienced personnel, more recent data shows, the success rate in detecting fetus abnormalities among high-risk pregnant women is 90 percent.

The difficult truth is that sometimes there is nothing doctors can do to save a fetus. Unfortunately, because C-sections have become so routine, the ''cure'' for a baby in trouble almost always means early delivery. Even if my child had survived his traumatic, early birth, there's a good chance he would have required special care for the rest of his life, something my doctor did not mention when she called delivery ''his best chance.''

The medical establishment has made extraordinary strides in preventing maternal and perinatal mortality in the last 50 years. But many hurdles remain. In the neonatal unit where my son died, roughly half the babies will not survive their first year. The rise of multiple births due to assisted reproduction has only exacerbated the problem. For parents, the uncertainties of those difficult births can be excruciating. For obstetricians, insurance premiums have soared as angry patients seek answers in court.

Medicine can't yet fix everything that can go wrong inside the womb. Often, the best it can do is tell parents what to expect -- and even then it isn't always right. We may fault the woman in Utah for her motives -- she has admitted using cocaine during her pregnancy and has been accused of making a remark about the resulting scar of a C-section -- but in the end, she may have made the right decision. At least one of her children survived.

Rebecca Johnson is on the advisory board at the Sloane Hospital for Women at the Columbia University Medical Center.